LAUSR

INTRODUCTION Agency for Healthcare Research and Quality Patient Safety Indicators (AHRQ-PSI) are quality improvement indicators used to determine hospital performance and, increasingly, to rank surgical programs. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the Society for Vascular Surgery Vascular Quality Improvement (SVS-VQI) databases are also frequently utilized to compare outcomes, but definitions of complications vary between the systems and the optimal system for tracking complications in complex endovascular repair remains unclear. Herein we assess the three outcome tracking systems and their ability to capture complications following fenestrated endovascular (FEVAR) and open aortic aneurysm (OAR) repair at a large complex aortic program. METHODS Demographic and operative data for patients undergoing repair of juxta- or pararenal aortic aneurysms between 2004 and 2018 via both open and FEVAR approaches at the Johns Hopkins Medical Institutions were compiled in a prospectively maintained retrospective database. Postoperative complications were defined according to a surgeon-defined system, SVS-VQI, ACS-NSQIP and AHRQ-PSI data dictionaries and were compared between surgical approaches as well as eras before and after the introduction of FEVAR. Complication rates between the classification systems were compared using proportion testing and strength of correlation between the systems was evaluated with Spearman's rank test. RESULTS Of 145 patients, 60 (41.4%) underwent FEVAR and 85 (58.6%) underwent OAR. Introduction of fenestrated technology was associated with a decrease in the overall number of complications (37.2% to 20.6% by surgeon-defined classification system, p=.036). VQI identified the most complications (39.9% of the entire cohort and 25% of FEVAR cases), followed by NSQIP (29.0% and 33.3%, respectively) and PSI (4.1% and 5%). The two clinically focused databases were found to correlate well with a surgeon-designed classification system as well as each other (Spearman ρ≥0.735) but not with PSI (ρ<0.23). Proportion testing demonstrated the rate of complications identified by PSI to be significantly less than either VQI or NSQIP (p<.001). Specifically, PSI did not effectively identify renal complications (1.4% vs. 9% by NSQIP and 27.3% by VQI definitions, p<.001). CONCLUSIONS The introduction of FEVAR is associated with an overall reduction in complications in this study. The clinically relevant VQI and NSQIP databases show good concordance in capturing complications; however, PSI did not correlate with either and captured significantly fewer complications. These data highlight the value of high scrutiny classification systems to track postoperative complications and suggests that PSI are insufficient to rank complex aortic programs with high levels of FEVAR utilization.